Ped/OB exam #3

postpartum blues

• resolves in 7-10 days

• usually self-limiting

Postpartum depression

• lasts beyond first few weeks- 6 months

• give therapy, nutrition/hydration, meds

postpartum psychosis

• hallucinations with thoughts of harm, suicidal

• psychiatric emergency

• never leave mom alone with baby

Autism

• ASD 1- difficulty initiating social interactions

• ASD 2- social interactions limited to narrow special interests; frequent restricted/ repetitive behaviors

• ASD 3- sever deficits in verbal and nonverbal social communication skills; great distress/difficulty changing actions or focus

what put children at risk for brain injury, skull fractures, spine injuries, and compression fractures

• big heads

• incomplete ossification of vertebra

• weaker neck and spinal muscles

• thin cranial bones

• excessive spine mobility

What is the first thing a nurse should consider when assessing neurologic status

• changes in level of consciousness is the earliest and most sensitive indicator

What are things to take into consideration when assessing a child’s mental status using the pediatric coma scale?

• check if the child is cared

• make questions age appropriate ex: what is your favorite cartoon?, that can you to check orientation

Decorticate

• extremities flexed inwards

• 10% mortality

Decerebrate

• extremities extended and pronated

• 70% mortality

What is increased ICP

• CSF in the subarachnoid space between the skull and the brain 

• cranium and vertebral body form a rigid container

What is a relief point for increase ICP in newborns?

anterior fontanelle

Early signs of increased ICP

• headache

• vomiting; could be projectile

• blurred vision, double vision

• dizziness

• increased blood pressure

• pupil reaction time decreased and unequal

• sunset eyes ( a lot fo white above colored part of eyes)

• changes in LOC

• seizure activity

infants

• bulging; tense fontanelle

• wide sutures and increase head circumference

• dilated scalp veins—> pulses bounding

• high-pitched cry

Late signs of increased ICP

• lowered level of consciousness

• decreased motor and sensory responses

• bradycardia

• irregular respirations

• hypertension and widening pulse pressure

• Cheyne-Stokes respirations—> rapid breathing then apnea

• decerebrate or decorticate posturing

• fixed and dilated pupils

Cushings triad

• widened pulse pressure

• bradycardia

• irregular respirations

What are some immediate nursing interventions to lower ICP?

• HOB up

• 100% oxygen

• PRN medications

• positioning

What are some causes of increased ICP?

• brain injury

• intracranial hemorrhage

• hydrocephalus

• medications

Shaken Baby syndrome clinical manifestations

• outside bleeding between brain and skull itself

• extreme irritability and/or lethargy

• poor feeding (eat a lot and throw up or not want to eat at all)

• vomiting

• full or bulging anterior fontanelle

• seizures

• loss of muscle tone

• oale or blue skin

• lethargic eyes

What is the immediate care for a patient with shaken baby syndrome

• observation

• ice pack

• AVOID ibuprofen and narcotics 

• allows sleep

• clear liquid if vomiting

• monitor LOC and status

What are some nursing assessments for a baby with shaken baby syndrome

• focused neuro asssesment

• vital signs q2

• loc: GCS

• reflexes

• pupil reaction

• worsening symptoms

• change in LOC

• N/V

• seizure

• Head size

What are some interventions for a baby with shaken baby syndrome

• antipyretics

• sedatives

• anti-seizure

• mannitol

• minimal stimulation protocol

• ROM

• hemodynamic stability positioning (staying midline)

• IV fluids

• scans prn

• Lumbar puncture

• surgical relief of pressure

Hydrocephalus

• bleeding directly into the ventricles of the brain

• congenital(present at birth); acquired (present after birth, injury, infection, tumor)

• infants—> bulging fontanelles and growing/large head circumference

• irritability

• nausea/vomiting

• visual changes

Ventriculoperitoneal shunt

• catheter placed in ventricle to relieve pressure from

• drains into the abdomen

EVD care and assessments

• zero it have it at the auditory meatus (tragus)

• ICP transduction

• neuro assessments

• site assessment—> CM LEVEL STILL IN BRAIN 

• can have kinking or clamping of tube (increase ICP)

• infection

• dislodgement

• make sure patient does not get up really fat b/c it can dump CSF out the brain

Seizure triggers

• birth injuries (anoxia, congenital defects)

• acute infections (late infancy and early childhood)

• can be idiopathic in children less that 3 years of age

Signs and symptoms of seizure activity

• change in LOC

• changes in perception, behaviors, sensations

• involuntary movements

• posturing

Teach parents how to respond if their child has a seizure

• remain calm

• ease child to ground

• tight neck clothing should be loosened

• place child on side to open airway

• do not restrain child

• remove hazards

• do not force jaw open

• document length, awareness level, movements, cyanosis, loss of bladder control

• remain with child until fully conscious

CALL EMS IF:

• child stops breathing

• injury has occured

• lasts more than 5 minutes

• child’s first

• child unresponsive to pain stimuli after

Medications for seizures

• carbamazepine (tegretol)—> monitor CBC and LFTs; can cause leukopenia, thrombocytopenia, pancreatitis, elevated liver enzymes

• Phenobarbital—> monitor blood level, can cause behavior problems, numerous interactions with other meds

• Lamotrigine—> increased risk of Steven-Johnson rash started very slowly

• Levetiracetam (keppra)—> can cause irritability

Seizure precutions nursing interventions

• maintain airwaay

• nothing inserted in mouth

• suction but not during

• monitor O2

• give meds—> get baseline liver and renal labs, monitor serum levels

• give IV meds

• raise pad and side rails

How does the delivery of placenta help with post-partum recovery?

• rapid fall in: progesterone, estrogen, relaxin

• tightens up= less risk for hemorrhage

• clamping down

Temperature, pulse, respirations, BP, pain, bleeding: Postpartum

• temp <100.4 (heightened immune response)

• pulse 60-80 (can increase from blood loss)

• RR 12-20

Blood pressure: Post-partum

• usually baseline

• possibly low from blood loss

Pain (postpartum)

• what’s acceptable to the patient

• ibuprofen/narcotics

Bleeding: Postpartum

• QBL less than 500 ml vaginally; less than 1000 ml C-section

• soaking a pad an hour is not good

why does the nurse have to stay with the newly delivered patient during their first trip to the bathroom?

• blood loss

• orthostatic hypotension

• voids a lot the first time

H&H: post-partum

• increase in hemoglobin and hematocrit

• could decrease if there is hemorrhage

WBC count

• 15,000- pregnancy

• 20,000- L&D

• 25,000- postpartum

• normally higher

What is the term for post-partum asasesment

• Breast

• Uterus

• Bowel

• Bladder

• Lochia

• Episiotomy

• Extremities

• Emotions

Breast assessment post partum 

• palpation: soft, firm, engorged

• nipple assessment: position, intact, discharge

• nutrition/hydration

• menstruation/contraception

Physiology of lactation

• supply and demand system

• newborn sucking on breast stimulates pituitary gland to release prolactin and oxytocin

• helps uterus go down, mom may feel cramping, helps bonding, breast milk synthesis

Breastfeeding problems

• incorrect latch

• supply issues

• sore nipples

• maastitis

• engorgement

• infection

• abcesses

Breastfeeding suppression

• no stimulation

• tigth fitting bra

• breast engorgement—> heat/cold, cabbage leaves, NSAIDs, expression

Breast feeding collection

• mauls or electric or cup breast pump

• hygiene and cleaning; expiration

Breast feeding weaning

• breast engorgement

• suppression

• return of menstruation

• emotional factors

Uterus post-partum

• fundal assessment: firm or boggy; height at umbilicus (goes down one cm a day) ; position midline or deviated (encourage urination) ; 10/14 uterus in pelvis more

Bladder post-partum

• urination: is blood in foley knicked bladder

• duresis

• trauma

• distention risk

• infection

Bowel post-partum

• assess sounds

• may be delayed because of epiduralas

• constipation

• pain and anxiety

Lochia post partum

• asses amount, color, clots, odor

• Rubra (bright red)

• serosa (darker brownish)

• alba (light, watery, whitish discharge

• pooling

• hemorrhage

Taking in emotions PP

• first 48 hours

• new life event

• cna eb traumatic

• putting the pieces together

• needs to tell her story

taking hold PP

• 2 days- 3 weeks

• starting to adapt

• focus on own health and care of baby

• possible start of PP blues

Letting go PP

• 1 month or more

• adapting to parenthood

• acceptance

• establish new routines

Nursing interventions for bonding PP

• uninterrupted private time for the family

• encourage skin-to-skin

• encourage mother to tell her birth story

• help family perceive infant’s cues

Postpartum Danger signs

• fever > 100.4

• foul-smelling lochia

• large blood clots or bleeding that saturates a pad an hour

• severe headaches, blurred vision, visual changes

• calf pain with dorsiflexion of the foot

• feeling faint, dizzy, or weak

• rapid heart rate

• swelling, redness, discharge at the episiotomy, epidural

• dysuria, burning, incomplete emptying of the bladder

• SOB

• depression or extreme mood swings

Discharge teaching postpartum

• do not lift anything heavier than the baby

• fruits veggies ect.

• how to care for infant

• wait 6 weeks for anything vaginally

• Rho gam (28 weeks and 72 hrs PP)

• do not give rubella during pregnancy

• follow up care at 6 weeks

Postpartum contraception

• avoid estrogen based with breastfeeding

• Depoprovera—> every 3 months, could take 18 months to resume fertility, high risk of brain tumors

• bilateral tube ligation—> considered permanent and irreversible; partner approval not necessary

Juvenile Arthritis pathophysiology

• autoimmune inflammatory process (unknown origin)

• exacerbations and remissions

• may be triggered by infection

• higher incidence in 1-3 and 8-12 and females

Juvenile Arthritis signs and symptoms

• joints: swollen, tender, warm to touch, stiff, decreased ROM, unable to use (bilateral grip strength impairment)

• fever in late day

• malaise

Juvenile Arthritis diagnosis

• by exclusion

• 6 weeks or more of joint pain and swelling

• rash

• WBC, CRP, ESR

• xray/bone scans to monitor changes

Juvenile arthritis nursing interventions

• protect ROM (PT/OT exercises)

• encourage activity

• diet to maintain bowel habits

• prevent injury and long-term disability

• pain management

Juvenile arthritis medications

• NSAIDs—> start with this but low

• Disease modifying antirheumatic drugs (DMARDS) (methotrexate) take an oral dose ounce a week

• steroid (given during exacerbations)

Sickle Cell pathophysiology

• defective form of hemoglobin

• HgS causes RBC to have characteristic sickle shape

Sickle Cell symptoms and sequelae

• cool to touch and poor oxygenation under occlusion

• jaundice—> rapid break down of RBC in body 

• anemia

• tissue hypoxia

• fatigue

• vasoocclusion

• weakness/pain

• pallor

• delayed G/D

Sickle cell nursing considerations

• encourage rest

• hydration 1.5 times above normal calculated requirements

• pain control—> NO ICE

• tell them to avoid: Ice, smoking, caffeine (vasoconstrictive)

What are some triggers for Sickle Cell Disease

• fever

• dehydraation

• altitude

• extremes in temperature

• vomiting

• emotional distress

• fatigue

• alcohol consumption

• pregnancy

• elevated hemoglobin

• elevated reticulocyte (immature RBC)

• excessive exercise

• acidosis

Muscular Dystrophies patho

• gradual wasting of symmetrical groups of skeletal muscle

• genetic anomaly

• Duchenne’s most common (absence of dystrophin that keeps muscle in tact)

• symptoms appear in preschool or very early school age

Muscular Dystrophies signs and symptoms

• getting up using hands or arms

• waddling; wide-based gait

• weak and hypertrophied calf muscles

Muscular Dystrophies diagnosis

• family history

• CK levels (will be high)

• definitive by muscle biopsy and electromyelogram

Muscular dystrophies supportive care

• PT/OT/respiratory

• independent living for as long as possible (completely caregiver dependent in early 20s bc of airway involvement)

• ROM, activity (swimming)

• prevent respiratory infection (flu vaccine, Chest PT)

• protect skin

• weight management (nutrient dense, low calorie, reduced fat, high fiber)

Cystic fibrosis pathophysiology

• thickened secretions

• respiratory—> obstruction, inflammation, decreased pulmonary function, right heart failure

• GI—> intestines, liver gallbladder affected; poor absorption of fats, pancreatic enzyme activity lost

• Reproductive—> thickened cervical/seminal fluid so they are likely infertile

Cystic fibrosis symptoms

• salty tasting skin

• chronic respiratory problems

• lung infections

• poor growth/weight loss

• meconium ileus

• bulky/greasy stool

Cystic fibrosis treatment care

• growth and development—> pancreatic enzymes with food, vitamins and supplements, high calorie/protein diet

• prevent/treat infection—> airway clearance, therapy/chest PT, abx, increase fluids

• mobilize secretions—> resp. medications, airway clearance tech/PT, postural drainage

• can lead to diabetes mellitus

Cerebral Palsy pathophysiology

• permanent disability of childhood related to severe prematurity (anoxia to brain)

• mild to severe physical and mental dysfunction

Cerebral Palsy symptoms

• muscle rigidity/ spatiscity

• muscular hypotonia or hypertonia

• poor control of posture

• ataxia

• primitive infant reflexes

What are some things the nurse would observe in a child that has cerebral palsy

• delayed motor reflexes (persistence of primitive reflexes)

• persistent or evolving increase or decrease in muscle tone (head lag beyond 6 months, poor trunk control, arching, abnormal movements, toe walking/scissoring, spasticity

• focal abnormalities of movement, tone, posture (hand preference prior to 18 months, differences in functional abilities in right and left)

• behavior differences (irritability and/or excessive crying, exaggerated startle response moro, jittery, sleep difficulties)

• physical ( decreased rate of head growth, poor weight gain, poor suck and or delayed feeding milestones)

Improve function and quality of life: Cerebral Palsy

• promote safety: swallowing, mobility

• prevent fatigue

• prevent growth and development

• promote nutrition (extra calories, may need a gastronomy tube for feedings)

• promote independence

• support intellectual development

• reduce muscle spasms

• constipation and GERD common

• osteopenia

• scoliosis

• increase risk for epilepsy

Collaborative care: Cerebral Palsy

• meds: reduce rigidity, reduce spasticity, muscle relaxants (baclofen, botox injections)

• therapy: PT, OT, speech

• adaptive equipment: walker, wheelchair, braces

• surgical interventions: hips, legs, wrists

What are the five T’s of hemorrhage

• tone

• tissue

• trauma

• thrombosis/clotting

• traction

Blood loss post-partum QBL

• primary within 24 hrs of delivery: less than 500 ml for vaginal; less than 1000 for c-section

• secondary 24hrs-12 weeks after delivery: abnormal or excessive bleeding

Tone

• boggy uterus

• risk factors: bladder distention, over-distention of uterus, precipitous or prolonged labor, labor induction/augmentation, mag sulfate use, infection

• signs/symptoms: soft uterus (boggy)

Tissue

• retained placenta, previa, accreta, uterine inversion

• most common cause of post-partum hemorrhage (uterus firms when you massage and then goes back to boggy)

• inspect placenta for intactness

• manual removal or D&C

Trauma

• lacerations, hematoma, uterine inversion

• signs/symptoms: bright red bleeding with firm fundus

• risk factors: precipitous or assisted delivery, previous uterine surgery, malposition or macrosomia

• emergent surgical repair

Thrombins/clotting

• coagulation disorders (DIC)

• bleeding with not identifiable cause

• risk factors: diagnosed conditions, family history, history of bleeding or PPH

• treat underlying cause!

• NOT FIXED BY FUNDAL MASSAGE

Traction

• excessive pulling on umbilical cord

• long 3rd stage of labor

• cord detachment or uterine inversion

• treatment: manual removal of placenta, surgical repair, potential hysterectomy

Post-partum Hemorrhage

interventions

• quick identification

• massage!

medications: uterotonics

• oxytocin (pitocin)

• prostaglandins: Carboprost (hemabate) or misoprostol (cytotec)—> ripens cervix and helps contract uterus down

• TXA

• Quantify blood loss

OB disorders and contraindications!

• cardiac disease DO NOT GIVE uterotonic, cytotec

• hypertension DO NOT GIVE methergine

• asthma DO NOT GIVE hemabate/cytotec

Secondary interventions of post-partum hemorrhage

• bimanual massage

• packing uterine cavity

• bakri balloon tamponade

• jada device (vacuum tamponade)

• ligate uterine artery, internal iliac artery

• hysterectomy

Preventing post-partum hemorrhage

• PPH risk assessment

• active, careful assessment and management

• staff readiness: hemorrhage cart, simulation, OB rapid response, quick (safe) lab, pharmacy, blood bank protocols

thromboembolism

• DVT

• PE

• EXTREME emergency

risk factors

• pregnancy

• diabetes

• obesity

• OCPs

• smoking

• bedrest

• C/S

Infection OB

• types: endometritis, surgical site infection, UTIs, Mastis, candidiasis, plugged milk ducts

• S/S: temp greater than 100.4, tachycardia, pain

• treatment: rest, hydration/nutrition, broad-spectrum abx, analgesics, wound management, good hygiene

What is the treatment for plugged milk ducts, mastitis, candidiasis

• frequent breast emptying (feeding or pumping)

• heat/ice

• analgesics

• any issues with baby